Chief complaint
History
Exam
Data
?
Diagnosis
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Goals
• How do you analyze diagnostic reasoning?
• How do you improve diagnostic reasoning?
Moving past…
Dx = ↓ fund of knowledge
Rx = see more, read more
Clinical Reasoning
1. Universal strategy.
2. Knowledge matters.
3. How knowledge is organized matters more.
Problem solving:
searching for a solution
Patient
Data
•History
•Physical Exam
•Laboratory
•Imaging
Problem
Representation
Illness
Scripts
1. Data Collection
4. Script
Selection
2. Problem Representation
3. Illness Scripts
Dx
Illness Script
•
•
•
•
•
•
•
•
•
•
•
History
Physical Exam
Labs
Imaging
Epidemiology (Risk Factors)
Pathophysiology
Treatment
Illness course
Memorable cases
Recent reading
Areas of ambiguity
Pneumonia
Pneumonia
Context (Risk Factors)
Clinical Features
(1) History (2) Exam (3) Labs
(4) Imaging/Advanced Studies
Pathophysiology
Treatments
Typical illness course with and without
treatment
Memorable cases / anecdotes
Recent reading / studies
Areas of ambiguity (in the field)
Areas of ambiguity (for you)
Clinical “pearls”
Content [edit]
1. Clinical Features
a. History
b. Physical
c. Labs/Imaging
2. Epidemiology
3. Pathophysiology
4. Treatment
5. Illness Course
Problem Representation
I have pain “under my right rib” “after I eat” “on
and off” “for the last 2 days” “really hurts”
Subacute recurrent severe post-prandial RUQ pain.
GERD
PUD
Costochondritis
Rib pain?
Abdominal pain?
Biliary Colic
Pancreatitis
Two days?
On and off pain?
Pneumonia
MI
UTI
Ulcer
Biliary Colic
Subacute, recurrent,
severe, post-prandial,
RUQ pain
Pancreatitis
Problem Representation
• defining features
• discriminating features
• abstraction of key clinical details
(e.g., prednisone 40mg daily  “immuncompromised”)
•
•
•
•
•
medical terms
temporal (e.g., acute vs. chronic)
qualitative (e.g., rest vs. exertional)
contextual (e.g., young vs. old)
eliminate nonspecific information
Subacute recurrent severe post-prandial RUQ pain
19 year old woman is
brought to the
emergency
department…
• 19 y/o woman w/ fever and headache.
• 19 y/o woman w/ fever, headache, and
unresponsiveness.
• Young healthy woman with URI followed by
fever, headache, AMS, and tachycardia.
• College student with fever, headache, and
neck pain/stiffness.
Step 4: Script Selection
Hypoxia
JVP ↑
WBC ↑
Fever
Edema
Infiltrates
Cough
Hypoxia
JVP ↑
WBC ↑
Fever
Edema
Infiltrates
Cough
Hypoxia
JVP ↑
WBC ↑
Fever
Edema
Infiltrates
Cough
Prioritized DDx
Match between
problem representation
and
illness script
I. Likely
Ib. Can’t Miss
II. Plausible
III. Unlikely
++++
variable
++
+/C. Lucey APDIM 2001
1. Data Collection
4. Script
Selection
2. Problem Representation
3. Illness Scripts
Dx
• Group 1: scenario 1
• Group 2: scenario 2
• Group 3: scenario 3
To Do:
• What is the Educational
Diagnosis?
– Use 4 steps
• What is the Educational
Plan?
1. His/her data collection is…. (fine)
2. His problem representation is …
3. His illness scripts are…
4. His script selection is…
My educational strategy is to ….
Case 1
42 year old man with acute left knee pain…
Case 1
•
Gut: good. On the right track.
1. Data collection: good…I can form a PR.
2. Problem representation: good
3. Illness Script: strong (for septic joint) / weak
4. Script selection: can’t tell
Building a script
Septic
Arthritis
Time
course
Site
Sudden
Exam
Febrile, unable
to range joint
Severity
Severe
Epi
Abnl joint,
bacteremia,
portal of
entry
Single Joint
?
Building a script
Septic
Arthritis
Septic
Prepatellar
bursitis
Time
course
Site
Sudden
Sudden
Single Joint
Single Joint
Exam
Febrile,
unable to
range joint
Some febrile, intact
but uncomfortable
range of motion,
bursa pain, erythema
Severity
Severe
Severe
Epi
Abnl joint,
Recent trauma,
bacteremia,
compression
portal of entry
Building a script
Septic
Arthritis
Septic
Prepatellar
bursitis
Our patient
(problem representation)
Time
course
Site
Sudden
Sudden
“acute”
Single Joint
Single Joint
“left knee”
Exam
Febrile,
unable to
move joint
Some febrile, intact
but uncomfortable
range of motion,
bursa pain, erythema
“in the front of the
Severity
Severe
Severe
Severe
Epi
Abnl joint,
Recent trauma,
bacteremia,
friction
portal of entry
joint… preserved
range of motion”
laying down carpet,
playing on floor
Case 2
Post-operative rounds…
Case 2
•
Gut: worried
1. Data collection: reasonable
2. Problem representation: lacking
3. Script contents: good
4. Script selection: can’t tell
Prioritized DDx
Match between
problem representation
and
illness script
I. Likely
Ib. Can’t Miss
II. Plausible
III. Unlikely
++++
variable
++
+
Data Problem Representation  DDx
Data
67 year old woman
Problem
representation
Hysterectomy 4 hours
ago
DM
Post-op (hours)
HTN
hysterectomy with
Elevated LFTs
HR 105
abdominal distention,
BP 92/50
tachycardia,
Hg 13.9  9.4
hypotension, and 4
Normal EKG
gm Hg decrease.
I/O +3 liters
Afebrile
Incision OK
Abdominal distention
Differential Diagnosis
I. Post-op intraabdominal bleeding
II. Perforation with
pneumoperitoneum
III. Decompensated
liver disease with
GI bleeding
Case 3
36 year old woman with
abdominal pain…
Case 3
•
Gut: not bad.
1. Data collection: good.
2. Problem representation: pretty good
(Although she didn’t mention tachycardia, EtOH, NSAIDs)
3. Script contents: hard to tell
4. Script selection: no, just a long list
Compare and Contrast
Peptic Ulcer
Disease
Pain (Location)
Quality
Radiation
Severity
Timing
Aggravate
Alleviate
Context
Ectopic
Pregnancy
Pancreatitits
epigastric
ache
back
severe
constant
food
sit up
EtOH or
gallstones
Cholecystitis
Gastroenteritis
Prioritized DDx
34 year old woman with 2 days of
epigastric pain and tenderness
and vomiting
I. Likely
Ib. Can’t Miss
Gastroenteritis, pancreatitis,
hepatitis
Ectopic pregnancy
II. Plausible
Pyelonephritis, cystitis
III. Unlikely
Inflammatory bowel disease
Your Next Teaching Encounter
Novice
Intermediate
Advanced
Model Practice Analyze
Problem
Representation
Compare and
Contrast
Prioritized
Differential
Diagnosis
www.improvediagnosis.org/ClincialReasoning